Provider Demographics
NPI:1508138199
Name:ENNIS, KIMBERLY DAWN (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DAWN
Last Name:ENNIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 567
Mailing Address - Street 2:
Mailing Address - City:GRIMESLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27837-0567
Mailing Address - Country:US
Mailing Address - Phone:252-847-2214
Mailing Address - Fax:252-847-7492
Practice Address - Street 1:513 LANCELOT STREET
Practice Address - Street 2:
Practice Address - City:GRIMESLAND
Practice Address - State:NC
Practice Address - Zip Code:27837-0567
Practice Address - Country:US
Practice Address - Phone:252-847-2214
Practice Address - Fax:252-847-7492
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0062511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical